Medications and Vitamins:
Name Dad/Mom goes by: Allergic to ……….. [make this red]
Primary diagnosis: ….. Stroke/TIA - 00-00-0000
Glasses: Radiation (location on body): 00-00-0000
Dentures: Knee Replacement – Left, 00-00-0000
Hearing aids: Hip Replacement – Right, 00-00-0000
Pneumonia Vaccine – yes
Blood Transfusion: 00-00-0000 (2 units) MGH Last Tetanus – unknown
THE MED TRAY: (one week, seven days, four times each day)
|Name |Tray |strength |Dosage |time |Rx by Dr |
| |Box | | | | |
|Tramadol (Ultracet) |37.5/325 mg |1 tab |As needed |Watson | |
|cream |0.1 % | |As needed |Watson | |
SUPPLEMENTS: on own
|Name |Strength |Dosage |Time |Purpose – Color and Shape |
|Senior Multi-vitamin | |1 |breakfast |- |
| |6 mg |1 |breakfast |- orange gelatin football |
| |400 iu |1 | |- |
| | |1 |breakfast & supper |- rolly brick oval |
| |1000 mg |1 |breakfast & supper |- |
Eye Drops:
|Name |strength |Dosage |time |Rx by Dr |purpose – color and shape - Notes |
| |0.5 % |One drop each eye|AM |Jekyll |Yellow cap/ ocular pressure |
| |0.03 % |One drop each eye|PM |Hyde | |
MGH blue card number: 111-11-1111
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